Healthcare Provider Details

I. General information

NPI: 1013306174
Provider Name (Legal Business Name): SPINE AND SPORTS SPECIALITIES MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W. LA VETA AVENUE SUITE 300
ORANGE CA
92868-4233
US

IV. Provider business mailing address

1120 W LA VETA AVE STE 300
ORANGE CA
92868-4246
US

V. Phone/Fax

Practice location:
  • Phone: 714-598-1745
  • Fax: 714-941-9539
Mailing address:
  • Phone: 714-598-1745
  • Fax: 714-941-9539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CORINNE WALKER
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 714-598-1745